Non-Fatal Strangulation Documentation Toolkit International Association of Forensic Nurses www.ForensicNurses.org November 2016 TABLE OF CONTENTS Preface i Strangulation Task Force Members 1 Purpose 3 Section I – Non-Fatal Strangulation Strangulation Assessment, Documentation, and Evidence Collection Guidelines 4 Section II – Non-Fatal Strangulation Policy and Procedure Example Policy and Procedure 7 Section III – Clinical Evaluation and Documentation Non-Fatal Strangulation Clinical Evaluation 9 Non-Fatal Strangulation Descriptors for Examiners 11 Non-Fatal Strangulation Documentation Form 14 Section IV – Discharge Instructions Example Strangulation Discharge Instructions 21 Additional Resources 22 References References 23 Bibliography Comprehensive Bibliography 25 PREFACE In 1992, The International Association of Forensic Nurses (IAFN) was created by a group of nurses that recognized violence as a healthcare problem. Over the past two and a half decades much progress has been made as it relates to the care of our specialized patient population. Through this progress, knowledge has been gained and practice guidelines continue to evolve with the goal of continuous provision of safe and effective patient care. In early 2015, the IAFN, the Board of Directors and a group of members recognized strangulation as a healthcare concern that needed practice guidance throughout the organization, and as a result, the Strangulation Task Force was created and was proven to be a group of hard working, dedicated individuals that are truly experts on strangulation. This group was tasked with establishing standards for the organization and developed what would be utilized as a toolkit for best practice provision. The Strangulation Toolkit provides the forensic nurse with detailed guidance on assessment techniques, documentation, and evidence collection for this patient population. This toolkit also provides documents such as discharge instructions and sample policies that can be adjusted to best suit your institution and your forensic practice. As a toolkit, it should be mentioned that the IAFN does not endorse any changes to these documents. Limitations of this toolkit include the lack of research available to guide our practice, making the need for additional research related to the management of the patient that has been strangled a high priority. Also, it should be mentioned that each clinician must refer to their own individual state practice acts when considering the implementation of any parts of this toolkit. The Strangulation Toolkit is the first of its kind to be endorsed by the IAFN and will be a useful guide to improving and standardizing the care of patients that have been strangled. As a group, we will continue to strive to move our profession forward and improve practice internationally and this toolkit proves to keep us on this path. International Association of Forensic Nurses www.ForensicNurses.org i STRANGULATION TASK FORCE MEMBERS Barbra Bachmeier, MSN, JD, NP-C (Chair) Nurse Practitioner/Forensic Nurse Examiner IU Health – Methodist Emergency Medicine and Trauma Center Indianapolis, IN Khara Breeden, DNP, MS, RN, SANE-A, SANE-P, CA/CP-SANE Missouri City, TX Teresa J. Devitt-Lynch, MSN, RN-BC, SANE-A, CFN, CMI-I, DACFEI United States Navy Navy Medicine Education and Training Command Joint Base-San Antonio, Fort Sam Houston, TX Ruth Downing, MSN, RN, CNP, SANE-A President and Founder Forensic Healthcare Consulting Delaware, OH Diana Faugno, MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN Eisenhower Medical Center Rancho Mirage, CA Sarah Hines, BSN, RN, CFN, SANE-A Eskenazi Health Center of Hope Indianapolis, IN Annie Lewis-O'Connor, PhD, MPH, NP-BC, FAAN Senior Nurse Scientist Founder and Director C.A.R.E. Clinic Brigham and Women's Hospital Boston, MA Jenifer Markowitz, ND, RN, WHNP-BC, SANE-A, DF-IAFN Alexandria, VA Jennifer Pierce-Weeks, RN, SANE-A, SANE-P Education Director International Association of Forensic Nurses Elkridge, MD Linda Reimer, BScN, RN, SANE-A, TITC-CT Domestic Abuse and Sexual Assault Care Centre of York Region Mackenzie Richmond Hill Hospital Richmond Hill, ON Holly Renz, RN, SANE-A, SANE-P Program Director Madison County SATC of Community Hospital Anderson, IN International Association of Forensic Nurses www.ForensicNurses.org 1 Suzanne Rotolo, PhD, MSN, RN, SANE-A, SANE-P, CFN, FACFEI Dr. Rotolo Consulting Leesburg, VA Bill Smock, MS, MD Police Surgeon Louisville Metro Police Department Clinical Professor of Emergency Medicine University of Louisville School of Medicine Louisville, KY Gael Strack, Esq. CEO and Co-Founder Training Institute on Strangulation Prevention, a program of Alliance for HOPE International San Diego, CA Sally Sturgeon DNP, RN, SANE-A, AFN-BC Forensic Nurse Examiner Institute of Clinical Forensic Medicine and Nursing Louisville, Kentucky Melissa Vesperman, BSN, RN, SANE-A Forensic Nurse Coordinator St. Croix Valley SART River Falls, WI Sarah Wells, BSN, RN, SANE-A, SANE-P Bon Secours Richmond Health System Bon Secours Richmond Forensic Nursing Services Richmond, VA International Association of Forensic Nurses www.ForensicNurses.org 2 PURPOSE The Non-Fatal Strangulation Documentation Toolkit was developed by consensus to assist clinicians in multiple settings and various disciplines with the evaluation of non-fatal strangulation. International Association of Forensic Nurses www.ForensicNurses.org 3 STRANGULATION ASSESSMENT, DOCUMENTATION, AND EVIDENCE COLLECTION GUIDELINES Equipment Needed ● Camera ● Measuring tape ● Evidence collection kit (swabs, sterile saline or water, envelopes, paper bags, evidence tape, etc.) ● ABFO No. 2 ruler ● Speculum ● Mannequin or Styrofoam head (optional) ● Gloves Definition Strangulation is a form of asphyxia produced by a constant application of pressure to the neck. The three forms of strangulation are: hanging, ligature, and manual. Hanging occurs when a person is suspended with a ligature around his or her neck, which constricts due to the gravitational pull of the person’s own body weight. Ligature strangulation occurs when the pressure applied around the neck is with a ligature only. Manual strangulation occurs when pressure is applied to the neck with hands, arms, or legs. (Ernoehazy, 2016; Funk & Schuppel, 2003; Line, Stanley, & Choi, 1985; Taliaferro, Hawley, McClane, & Strack, 2009; Wilbur et al., 2001). Anatomy/Pathophysiology Pressure around the neck can result in the closure of blood vessels and/or air passages. Injury and death from strangulation occur from one or more mechanisms. The first mechanism is venous obstruction, whereby occlusion of the jugular veins results in congestion of the blood vessels and increased venous and intracranial pressure. The second mechanism is carotid artery obstruction, which stops blood flow and impedes oxygen delivery to the brain. The third mechanism is pressure on the carotid sinus that can cause acute bradycardia and/or cardiac arrest. Strangulation can result in injuries to the soft tissues of the neck, esophagus, larynx, trachea, cervical spine, and the laryngeal and facial nerves. (Hawley, McClane, & Strack, 2001; Shields, Corey, Weakley-Jones, & Stewart, 2010; Smith, Mills, & Taliaferro, 2001; Taliaferro, Hawley, McClane, & Strack, 2009). © 2016 CFNEI. All rights reserved. May not be reproduced, published, distributed, displayed, performed, copied, or stored for public or private use without the written permission of CFNEI. International Association of Forensic Nurses www.ForensicNurses.org 4 History/Patient Description of the Strangulation Event Describe what happened, using the patient’s own words. Place quotation marks around the patient’s comments. Also, describe the patient’s appearance, behavior, speech, eye contact, and affect/demeanor using terms such as “slumped,” “weeping,” “averting eye contact,” “stammering,” “somber,” “agitated,” etc. Include the assailant’s name, date of birth, and his or her relationship to the patient. Attach additional pages, if needed. Below are specific questions to ask each patient who reports strangulation. (As needed, reword questions to the appropriate developmental level of the patient.) ● Describe and demonstrate on the head model how you were strangled. One hand? Two hands? Arm? Leg? Other object(s)? ● How many times were you strangled?/Over what period of time? ● Were you shaken while you were being strangled? ● Was your head pounded on the ground or wall while you were being strangled? ● Did your feet leave the ground while you were being strangled? ● How long did the strangulation(s) last? ● On a scale of 0–10, how much pressure was applied to your neck during the strangulation(s)? ● What did you think was going to happen? ● What did the assailant say to you before, during, and after you were strangled? ● What made the person stop strangling you? ● Were you suffocated (defined as smothered)? (Suffocation refers to obstruction of the airway at the nose or mouth.) ● Did you have any difficulty breathing or an inability to breathe? ● Did you or do you currently have a cough? ● Did you or do you currently have trouble swallowing? ● Did you have a hoarse, raspy, or complete loss of voice? ● Did you or do you currently have any changes in your vision? (seeing spots, tunnel vision, blurry vision, everything went black, etc.) ● Did you or do you currently have any changes in your hearing? (roaring, ringing, etc.) ● Did you become dizzy or lightheaded? ● Did you lose consciousness? (passed out, blacked out, etc.) ● Did you experience any mental status